Q&A with Professor Alice Miller

Professor Alice Miller is an Associate Professor (Adjunct) of Law at Yale Law School and co-director of the new Global Health Justice Partnership. As an expert in health, human rights, and gender, Professor Miller also holds positions at the Yale School of Public Health and the Jackson Institute for Global Affairs. Her extensive research has focused on gendering humanitarian law, abolition of the death penalty, sexual and reproductive health, and LGBT rights.

Yale Global Health Review: How do you straddle the line between academia and advocacy? Being taken seriously but also making sure that your work has meaningful impact for populations in the near future?

Alice Miller: You need mutual respect between advocates and scholars; they have a lot to teach each other.

The academic should understand that the ideal is not what’s possible in the real world. Their ideas are to help do a better job and not a blueprint for how activists should act… It’s more important to be relevant in the midst of things than to be understood as perfect.

There’s a tendency in human rights work in general – particularly concerning sexuality and human health – to make people innocents: “an innocent person was raped or got HIV. If an innocent person getting raped is a terrible thing, does that mean that it’s okay to rape guilty people?” It’s a great tactic… A great poster. Many advocates tend toward highlighting innocents as a way of making their claim stronger.

My work as a scholar is to point out the ways in which claims about innocents are often quite dangerous to long-term change because guilty people, in the general sense and not just the political sense, need rights too. People who don’t live blameless lives still have the right not to be tortured, not to be raped, the right to live in a house.

If you’re a scholar, your allegiance is to your idea or institution. As your question implies, sometimes scholarship is understood as being above the fray. And that’s how it gets respect. I’ve been lucky enough to work with a kind of coterie of scholar activists – people who are committed to long-term social change and also committed to rigorous thinking and are willing to be in the fray. It’s an interesting challenge.

YGHR: Would the new law passed in Uganda be something that falls within your scope?

AM: Which one? The one on women and pornography or the one on anti-gay?

YGHR: The one on anti-gay.

AM: Part of what I’m doing by asking the other question is that one of the interesting things about doing health and sexuality is that right now, stuff on gay rights is on everyone’s radar, but stuff on women’s rights not on everyone’s radar! Uganda also passed a law about women and pornography that, among other things, makes women wearing short skirts forbidden and that women shouldn’t read certain things or be in certain areas to protect their virtue. Nobody knows about that because the kinds of women’s rights conversations are not on the agenda but the gay rights one is. I work on both, so I want attention to both.

YGHR: Do you ever get frustrated when people only get concerned about human rights when it’s in the news”

AM: Yes. Both when it’s in the news and the way that it’s in the news which goes back to my discussion of innocents being the kind of headline grabbing version.

For example, Nicholas Kristof, as a New York Times editorialist, has incredible space to talk about and tries to bring attention to all kinds of things from obstetric fistula in Sub-Saharan Africa to sexual violence in the Sudan. But it turns out that his kind of attention-grabbing writing is actually counterproductive to sustainable long-term change.

Obstetric fistula is a condition for women that generally happens if you’ve had prolonged labor in childbirth or sometimes particularly vicious sexual violence. Basically, the wall between your vaginal wall and intestinal wall is broken down, so that you leak feces and urine. You don’t die of it, you are often sick, but you’re definitely outcast.

Kristof has been doing a series of columns about the horrors of this, which is great; people should know about the horrors of this terrible condition – the women don’t die but they nonetheless suffer. On the other hand, he focuses on treatment because he doesn’t want to do the politics of contraception or birth control.

Unfortunately, because of the way that a couple of Op-Eds have run, people think that what we need are what they call vagina doctors, doctors to treat people. Which is great work because obviously it’s helping any woman who suffers. But you can’t treat your way out of this problem. A functioning health system alongside with good clean water, good air, good food, and the ability to move about and make decisions to control your life are the most fundamental things that can give you good health. But those are not the stuff of headlines.

For those of us who do health and human rights, we spend a lot of time trying to think about how is it we can really get long term system change while dealing with the headlines we face every day. Can we use these headlines strategically and still accomplish the long-term systems change even though the headlines are all about individual heroes and individual victims. That’s a big part of health and human rights work.

YGHR: What is one accomplishment you are proud of? What is something you are not very proud of?

AM: I think the proudest is having been part of a group of people who help to open up the conversation about sexuality as a human right. The “not proud” is that it instantly turned into a much too rigid conversation about gay identity in one corner and sexuality and women’s rights in the other. We fell into our own rut of belief that “what matters to women about sexuality is rape and what matters to other people about sexual difference is gayness, and that’s mostly men”. That‘s a real problem. I was part of the good part of the conversation and part of the bad part of the conversation.

YGHR: This kind of sounds like the Uganda law debate we talked about earlier.

AM: Exactly! At root they represent the same impulse to control anything that is gender nonconforming, anything that threatens a certain image of masculinity and femininity–against which nobody lives perfectly. It’s a thing used to govern and repress people; whether it’s heterosexual women, heterosexual men, or people who prefer to live a different gender life, or women who would like to live without husbands. All of those people are equally repressed under these systems, but we only get headlines on a few. It’s an odd moment; twenty years ago you couldn’t get newspapers to talk about the harm against people with same-sex behavior. Now you can’t get them to stop. Twenty years ago, we couldn’t get them to think of rape as a problem for women’s human rights, now I can’t get them to think of anything else. We were onto something, but we didn’t budge all the background conservative ideas around it.

YGHR: Consider the following WHO statement: “Indeed, inadvertent discrimination is so prevalent that all public health policies and programs should be considered discriminatory until proven otherwise, placing the burden on public health to affirm and ensure its respect for human rights.” Can you give an example of a nuanced public health program that seemed valid but has underlying it very discriminatory elements.

AM: Let’s say you run a health service, a clinic, and your hours are 9-5 because those are work hours. Who aren’t you going to see at your clinic?

YGHR: People who have to work from 9-5.

AM: Exactly, people who are the poorest are often the ones with the least ability to manipulate their work hours to get health services for themselves or their children. If you’re going to have a clinic, how do you have hours to accommodate the people who are the most marginalized? If you are punching a time clock, if you have to lose pay to go see a doctor or take your kid to a doctor, that’s not a choice you can make. You can locate a community clinic in a poor part of town, but if your hours don’t meet what people can do, you will only get a certain number of people and won’t get others.

You need to say now I need to have different hours or now I need to have a mobile van if I want to work with street folks. No matter how good your services are, you haven’t thought through barriers that people face

Similarly, maybe not in the U.S. anymore, but it used to be that women couldn’t get health services without their husbands’ permission. So if you’re set up planning, but you haven’t understood how it is that a woman can walk through the door and actually get information about family planning. If you haven’t thought about the ways in which she’s required to produce a male heir, no matter what you’re telling her, she may or may not be able to act on it. In that sense, you aren’t helping her enjoy her health and human rights, and you may be actively contributing to further barriers.

A human rights analysis around health services would require you to think about material barriers that people face above the contents of your services.

YGHR: How do you react when people criticize international health efforts as hypocritical or a misuse of resources when the United States itself has big health/human rights-related issues?

AM: The US is always the site of its own problems, and, because we hold one quarter of the world’s wealth, we are always part of other people’s problems. I don’t see how you cannot do both. In our Global Health Justice Partnership we try to do projects both inside and outside the US to remind people that both are happening.

If you do a project that says I’m going to fix other people, but I’m not going to acknowledge what’s wrong with the U.S., then you’re wrong. If you do a project that says the U.S. is a part of the problem, especially if you’re talking about anything related to the world bank, (IMF), our policies are part of the problem– they are PART, not the only part, of the solution. You can’t be high-handed.

I think it’s a combination of always having both eyes wide open, one looking internally and one looking externally. And making clear that when you think you’re doing international work, you’re not just re-imposing US values. Not just saying the U.S. screwed up by imposing one kind of value, but now I’m going to fix it by imposing another kind of value. What’s you’re actual accountability to people who are most affected in another country – can they yell at you? Do you know what they’re doing? Do you know what they need? Do you know how diverse they are? Do you know how many “they”s there are? How many different kinds of groups can do what kind of work?

What’s the best relationship to be in? Maybe you need to be visible, maybe you need to be invisible. Maybe they need a U.S. partner for validity, maybe they don’t need a U.S. partner because it will invalidate them?

At any given moment, it will be complicated.

YGHR: What is the most common or most problematic misconception you hear from students or the public about health and human rights?

AM: One of the biggest misconceptions, particularly in the United States, is that health is produced by more healthcare. That is a really, really, really big problem.. If you know Betsy Bradley’s work, the percentage of good health outcomes that are affected by health care by itself is somewhere between 20 and 30% But health is affected by a whole range of other factors – social determinants. They’re things that matter – everything from where you live to what food you get to what kind of play space your kids have. Those things are the building blocks of health – adding healthcare is an important component but not the majority of what makes good health.

In my specific work around sexual health, the misconceptions include things like “rape happens in all wars at the same rate against all women”. It turns out, in some wars, it doesn’t happen at all. In some wars, one side rapes and the other side doesn’t. For me, it’s about finding variation. People who work on the ground, who go into refugee camps, know this; you need to deal with men who were raped too; that women are having many different kinds of sex, some chosen, some forced, not all of which is rape from the enemy. When you’re designing programs that do health interventions in conflicts, you need to design services where people are at and that meet people’s needs that are much more varied. Varied stories are really hard to make headlines on.

YGHR: What do you think is ONE BIG concern in human rights and sexual health today?

AM: The fact that we still see the problems as separate – that we’ve divided off gay rights from women’s rights. That we think sexual health isn’t about housing rights.

I think the biggest problem is we have to prioritize, but we have to not separate. The biggest problem is working on things in silos as if you could pull one thread and fix it. I think you have to identity your threads and be clear, but you can never just pull one thread. Therefore, silver bullet solutions are a big problem – short-term technological solutions to health problems, basically solutions that the Gates Foundation likes to fund.

YGHR: Rather than institutional and structural change?

AM: Right. And of COURSE we want technology on our side: of course we want new vaccines, of course we want mosquito nets, of course we want new immunizations. But by themselves, they don’t work; unfortunately right now, the biggest money is flowing towards those issues. That kind of single thread driven answer is a problem.